ASGE Postgraduate Course at ACG 2022: Expanding the Scope of Fundamental and Advanced Endoscopy | October 2022-4 BARKUN Risk Stratification and Treatment of UGI Bleeding

4 BARKUN Risk Stratification and Treatment of UGI Bleeding

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This document summarizes a state-of-the-art lecture on the risk stratification and treatment of upper gastrointestinal bleeding (UGIB). The overall mortality rate for non-variceal UGIB is 1.1-11% and has decreased over the past 10 years. Mortality is mainly related to co-morbid illnesses rather than the bleeding itself. Endoscopic hemostasis is the cornerstone of therapy for high-risk lesions, with proton pump inhibitors (PPIs) used as an adjuvant. Patients with UGIB who are classified as very low risk (Glasgow-Blatchford score of 0 or 1) can be discharged with outpatient follow-up rather than being admitted to the hospital. Nasogastric tubes are not required as they do not improve visualization of the gastric mucosa. Red blood cell transfusion should follow a restrictive policy with a threshold of hemoglobin of 7 g/dL. Prokinetic therapy with erythromycin before endoscopy improves mucosa visualization and reduces the need for a second-look endoscopy. The use of PPIs before endoscopy is not recommended, except in cases of delays in endoscopy or bleeding from a non-variceal etiology. Endoscopy should be done within 24 hours for patients with UGIB. Endoscopic therapy is recommended for ulcers with active spurting, active oozing, and non-bleeding visible vessels, while treatment for ulcers with adherent clot resistant to vigorous irrigation is uncertain. Hemostatic modalities include bipolar electrocoagulation, heater probe, injection of absolute ethanol, through-the-scope clips, argon plasma coagulation, and soft monopolar electrocoagulation. Hemostatic powders/gels can be used as supplemental therapy, but cost-effectiveness may vary. For patients on anticoagulants or antiplatelet agents, management recommendations are provided. Overall, this summary highlights key points in the risk stratification and treatment of UGIB.

Keywords

upper gastrointestinal bleeding

risk stratification

treatment

mortality rate

endoscopic hemostasis

proton pump inhibitors

Glasgow-Blatchford score

red blood cell transfusion

prokinetic therapy

hemostatic modalities